I love being a doctor but I hate practicing medicine, a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates and a poster of an illuminated lighthouse that read: Success doesnt come to you. You go to it.

A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; his days, he said, will be totally busy.

Your days arent busy enough already? I asked.

The waiting room was packed. He had a full schedule of appointments, and after he was done with his office patients, he was going to round at two hospitals.

He smiled wanly. Just look at my eyes.

They were bloodshot.

This whole week I havent slept more than about six hours a night.

I asked when his work usually got done.

It is never done, he replied, shaking his head. See this pile?

He pointed to five large manila packages on a shelf above his desk. These are reports I still have to finish.

As a physician, I could empathize. I too often feel overwhelmed with paperwork. But my friends discontent seemed to run much deeper than that. Unfortunately, he is not alone. I have been hearing physician colleagues voice a level of dissatisfaction with medical practice that is alarming.

In a survey last year of nearly 2,400 physicians conducted by a physician recruiting firm, locumtenens.com, 3 percent said they were not frustrated by nonclinical aspects of medicine. The level of frustration has increased with nearly every survey.

It will take real structural change in the work environment for physician satisfaction to improve, Dr. Mark Linzer, an internist at the University of Wisconsin who has done extensive research on physician unhappiness, told me. Fortunately, the data show that physicians are willing to put up with a lot before giving up.

Not long ago, fed up with what he perceived as a loss of professional autonomy, Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens.

Id write a prescription, he told me, and then insurance companies would put restrictions on almost every medication. Id get a call: Drug not covered. Write a different prescription or get preauthorization. If I ordered an M.R.I., Id have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.

When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.

But managed care is like a magnet attached to you, he said.

He continues to be frustrated by payment denials. Thirty percent of my hospital admissions are being denied. Theres a 45-day limit on the appeal. You dont bill in time, you lose everything. Youre discussing this with a managed-care rep on the phone and you think: Youre sitting there, Im sitting here. How do you know anything about this patient? 

Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. Ninety percent of doctors I know are fed up with medicine, he said.

And it is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors lounges. Malpractice worries also remain at the forefront of many physicians minds, compounded by increasing liability premiums that have forced many into early retirement.

In surveys, increasing numbers of doctors attest to diminishing enthusiasm for medicine and say they would discourage a friend or family member from going into the profession.

The dissatisfaction would probably not have reached such a fever pitch if reimbursement had kept pace with doctors expectations. But it has not.

Doctors are working harder and faster to maintain income, even as staff salaries and costs of living continue to increase. Some have resorted to selling herbs and vitamins retail out of their offices to make up for decreasing revenue. Others are limiting their practices just to patients who can pay out of pocket.

There are serious consequences to this discontent, the most worrisome of which is that it is difficult for doctors who are so unhappy to provide good care.

Another is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners.

Last year, residency programs in family practice took only 1,096 graduating medical students, the fewest in the last two decades. The number increased just slightly this year. Students who do choose internal medicine increasingly are forgoing primary care for subspecialty practices like cardiology and gastroenterology.

For me its an endless amount of work that I can never get through to do it properly, said Dr. Jeffrey Freilich, 38, a primary-care physician on Long Island. Im a bit compulsive. As an internist, I have to worry about working up so many conditions  anemia, thyroid problems and so forth. There is no time to do it all in a day.

On top of all that, there are all the colonoscopies and mammograms you have to arrange, and all the time on the phone getting preauthorizations. Then you have to track the patient down. And none of it is reimbursed.

Many primary-care physicians have stopped seeing their patients when they are hospitalized, relying instead on hospitalists devoted to inpatient care. Internists have told me that it is prohibitively inefficient to drive to a hospital, find parking, walk to the wards, examine a patient, check laboratory tests and vital signs, talk to a nurse and write orders and a note  for just a handful of cases. They cannot afford to leave their offices long enough to do it.

The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today.

Years ago you had one or two doctors, a hospitalized patient told me recently. Now youve got so many people coming in its hard to know whos who.

A 10.6 percent cut in Medicare payments to physicians is scheduled to take effect on July 1. Further cuts are planned in coming years. Many doctors have told lawmakers that if the cuts go through, they will stop seeing Medicare patients. But reimbursement cuts are only a small part of doctors woes today.

I was naïve, Saeed Siddiqui said. When I was a resident I thought it was enough to take good care of patients. But the real world is totally different.

Dr. Sandeep Jauhar, a cardiologist on Long Island, is the author of a new memoir, Intern: A Doctors Initiation.

I think the insurance figured it out... if we make it involve doing work like making a phone call or filling a form then doctors wont do it. They cut their costs that way and patients generally suffer.

You get what you pay for, which is a scary thought when you look at it from the patient's eyes. The system however is about to be changed a lot as things become paperless. We might start seeing internal hospital systems that actually recommend meds to doctors based on insurance. That's when you know insurance is a broken theme. Some of the "middle man" staff will be cut out as orders and progress notes go to being the computer.

Doctors need to stop being unpaid middlemen and reject insurance, public and private. Let the patients fill out the forms and sit on hold for hours to get reimbursed for the cash or cash equivalent they already paid you. You'll see some streamlining to the system when all of their customers start getting fed up with the bureaucracy. And if not, what do you care, you already got paid.

Doctors need to stop being unpaid middlemen and reject insurance, public and private. Let the patients fill out the forms and sit on hold for hours to get reimbursed for the cash or cash equivalent they already paid you. You'll see some streamlining to the system when all of their customers start getting fed up with the bureaucracy. And if not, what do you care, you already got paid.

Doctors need to stop being unpaid middlemen and reject insurance, public and private. Let the patients fill out the forms and sit on hold for hours to get reimbursed for the cash or cash equivalent they already paid you. You'll see some streamlining to the system when all of their customers start getting fed up with the bureaucracy. And if not, what do you care, you already got paid.

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Good idea on the surface -- unfortnately it could only work for low cost E&M (or well heeled individuals). Also, if fails to address the global issue and merely transfers financial risk from provider to consumer -- who already paid for a significant portion of their care through health insurance premiums.

Good idea on the surface -- unfortnately it could only work for low cost E&M (or well heeled individuals). Also, if fails to address the global issue and merely transfers financial risk from provider to consumer -- who already paid for a significant portion of their care through health insurance premiums.

Problematic....

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At the risk of sounding redundant to myself (and to many others on this board), Health insurance should work like car insurance or homeowners insurance. It should cover the catastrophes, while the low end stuff should be paid by the consumer. If we could collect in the ER, the same people pay to fix and engine in their car (something that most of us have had to do ), I believe that we could largely eliminate the need for insurance payments in medicine that doesn't require long term high cost treatment (like chemo) or acute hospitalization. By eliminating the middleman in primary care, insurance premiums should drop by a greater proportion than the majority of people will then pay out in physician payments. They might even get better care, as the time that physicians are using to fight with the insurance companies might be better used to entice consumers to come to their practices in a new free market in primary care. I think everyone would prefer that.

Of course, we would need to change the environment to one in which the consumer has a clue what things cost (which means doctors have to know) and in which you don't get sued for not ordering the most expensive test. We can dream though.

I think the insurance figured it out... if we make it involve doing work like making a phone call or filling a form then doctors wont do it. They cut their costs that way and patients generally suffer.

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Insurance is shady. I've seen them deny claims that should be covered but aren't due to "a simple clerical error" on their part. All it takes is a phone call and a little medical knowledge to clear it up. I have no doubt that they do this on purpose figuring most people will not fight the rejection. If you do try to fight it you are magically put on hold for 30 minutes (Vs. little to no waiting time if you want to sign up for a new plan) which again I'm sure is another one of their cost saving tactics.

At the risk of sounding redundant to myself (and to many others on this board), Health insurance should work like car insurance or homeowners insurance. It should cover the catastrophes, while the low end stuff should be paid by the consumer. If we could collect in the ER, the same people pay to fix and engine in their car (something that most of us have had to do ), I believe that we could largely eliminate the need for insurance payments in medicine that doesn't require long term high cost treatment (like chemo) or acute hospitalization. By eliminating the middleman in primary care, insurance premiums should drop by a greater proportion than the majority of people will then pay out in physician payments. They might even get better care, as the time that physicians are using to fight with the insurance companies might be better used to entice consumers to come to their practices in a new free market in primary care. I think everyone would prefer that.

Of course, we would need to change the environment to one in which the consumer has a clue what things cost (which means doctors have to know) and in which you don't get sued for not ordering the most expensive test. We can dream though.

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The problem is that people are so use to the gold plated insurance that employers use to hand out. This means the middle to upper class who have always had these plans are not very open to the idea of paying out of pocket even though in most cases a HSA and high deductable plan would save them money.
Ironically it's the working and lower income families who are more open to pay out of pocket especially if you through in any kind of convenience into your practice. I can't remember which direct practice it was, but when they converted from insurance to cash only the majority of people who left the practice were those in the upper middle class while the majority of those with lower incomes stayed on.

The problem is that people are so use to the gold plated insurance that employers use to hand out. This means the middle to upper class who have always had these plans are not very open to the idea of paying out of pocket even though in most cases a HSA and high deductable plan would save them money.
Ironically it's the working and lower income families who are more open to pay out of pocket especially if you through in any kind of convenience into your practice. I can't remember which direct practice it was, but when they converted from insurance to cash only the majority of people who left the practice were those in the upper middle class while the majority of those with lower incomes stayed on.

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I've heard that as well. Cash practices tend to attract a large blue-collar clientele. This is pretty much what I do. I carry a near catastrophic health insurance plan, and I tend to negotiate cash payments for primary care. Interestingly enough, those gold-plated insurance plans only came into existance in retaliation to FDRs price controls during the great depression as a way to entice employees (since it was illegal to just pay more).

The idea of for-profit insurance companies and hospitals is upsetting to me. All healthcare organizations and insurers/HMO's should be non-profit.

Regarding patients paying for primary care themselves and insurers only covering catastrophic coverage, I think this is a really bad idea. Patients will opt not to go to primary care physicians to control HTN, diabetes, etc. because they don't feel sick. This will increase emergent and urgent cases in the ED and hospitalization when such things could be prevented. This will increase healthcare expenditures. Studies have shown that those that seek primary care and prevent illness or treat it in its earliest stages have lower healthcare costs overall.

Perhaps we should have insurers pay for preventive medicine but not for catastrophic things that could have been prevented. That would save healthcare dollars and would encourage people to see a primary care physician regularly.

The idea of for-profit insurance companies and hospitals is upsetting to me. All healthcare organizations and insurers/HMO's should be non-profit.

Regarding patients paying for primary care themselves and insurers only covering catastrophic coverage, I think this is a really bad idea. Patients will opt not to go to primary care physicians to control HTN, diabetes, etc. because they don't feel sick. This will increase emergent and urgent cases in the ED and hospitalization when such things could be prevented. This will increase healthcare expenditures. Studies have shown that those that seek primary care and prevent illness or treat it in its earliest stages have lower healthcare costs overall.

Perhaps we should have insurers pay for preventive medicine but not for catastrophic things that could have been prevented. That would save healthcare dollars and would encourage people to see a primary care physician regularly.

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A free market would create innovative solutions to this problem. As an example, catastrophic insurance might be predicated on attending an annual physical, or maintaining some level of glucose or HTN control. Catastrophic insurance would also probably maintain deductables that made primary care still cheaper to the consumer.

P.S. Is there something wrong with a free market that contains both for-profit and non-profit insurers, with the consumer able to go to whichever he feels best serves him?

A free market would create innovative solutions to this problem. As an example, catastrophic insurance might be predicated on attending an annual physical, or maintaining some level of glucose or HTN control. Catastrophic insurance would also probably maintain deductables that made primary care still cheaper to the consumer.

P.S. Is there something wrong with a free market that contains both for-profit and non-profit insurers, with the consumer able to go to whichever he feels best serves him?

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The only problem is that there is not that much incentive to maintain your catastrophic insurance, because everyone knows they will get taken care of regardless. When someone without insurance comes into the ER with an MI or trauma, they will get care, insured or not. Then the hospital or the government will have to foot the bill. This is why it may be a good idea to make some kind of catastrophic insurance mandatory, like car insurance is.

It is just stupid and inefficient to have insurance pay for physicals and URI's, though.

The only problem is that there is not that much incentive to maintain your catastrophic insurance, because everyone knows they will get taken care of regardless. When someone without insurance comes into the ER with an MI or trauma, they will get care, insured or not. Then the hospital or the government will have to foot the bill. This is why it may be a good idea to make some kind of catastrophic insurance mandatory, like car insurance is.

It is just stupid and inefficient to have insurance pay for physicals and URI's, though.

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Except that unlike car insurance, individuals can't simply choose to not drive a car. This is essentially forcing every American to pay money to a specific industry against their individual wills. A better solution might be to repeal EMTALA and make it so that those that are uninsured are either sent to county facilities or charity facilities, providing a great incentive to insure oneself by simply removing one more artificial incentive in the marketplace. Another solution might be to improve on the predatory legal environment in which we live, so that those that don't pay their bills lose the right to sue.

There are many solutions, and I don't claim to have all of the answers off of the top of my head, but your whole argument as to why the insurance ought to be mandatory is predicated on the artifical incentives that we have (EMTALA, medico-legal persuasion) that are already disincentivizing catastrophic insurance. If everyone didn't automatically know that they would get treatment, they would protect themselves at a much higher rate. Of course, we could also just go to a system in which having limited means to pay meant that you got less expensive treatment (shock). There wasn't massive dying in the street before EMTALA and its existance is the reason that the negative incentives exist.

The idea of for-profit insurance companies and hospitals is upsetting to me. All healthcare organizations and insurers/HMO's should be non-profit.

Regarding patients paying for primary care themselves and insurers only covering catastrophic coverage, I think this is a really bad idea. Patients will opt not to go to primary care physicians to control HTN, diabetes, etc. because they don't feel sick. This will increase emergent and urgent cases in the ED and hospitalization when such things could be prevented. This will increase healthcare expenditures. Studies have shown that those that seek primary care and prevent illness or treat it in its earliest stages have lower healthcare costs overall.

Perhaps we should have insurers pay for preventive medicine but not for catastrophic things that could have been prevented. That would save healthcare dollars and would encourage people to see a primary care physician regularly.

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Car insurance companies (at least in Texas) offer decent discounts on the premium for people that choose to attend defensive driving classes. I don't see a reason that catastrophic health insurance policies couldn't offer the same thing. With your receipt, you get a certificate or card and mail a copy to your carrier. Now you've got an incentive to keep up on your primary care. If primary care were free market, you'd probably see physician's fees fall to affordable amounts and it would be profitable for people to pay $50-75 for an annual checkup if it meant they'd save $150/year on their insurance premiums.

I don't think we should want our society to determine where patients will be treated based on insurance status rather than proximity and resources of the hospital. Especially in the case of a catastrophic event, time can be one of the most important factors. If a patient has to drive 10 more miles to the county facility, that could be the difference between life and death.

Although EMTALA is a bad law, it was envisioned to prevent just this type of scenario. Hospitals are required to examine and stabilize a patient before transferring to another facility. In emergencies this is a good thing. A private hospital should not be able to refuse someone who could be actively dying due to lack of insurance. The problem is that ER staff is getting bogged down examining UTI's and viruses instead of the urgent situations the law should cover. I think EMTALA could be modified to cover only patients presenting with certain symptoms (chest pain, acute abdomen, trauma, etc.).

Except that unlike car insurance, individuals can't simply choose to not drive a car. This is essentially forcing every American to pay money to a specific industry against their individual wills. A better solution might be to repeal EMTALA and make it so that those that are uninsured are either sent to county facilities or charity facilities, providing a great incentive to insure oneself by simply removing one more artificial incentive in the marketplace. Another solution might be to improve on the predatory legal environment in which we live, so that those that don't pay their bills lose the right to sue.

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If we do not force people to get insurance, we are still forcing every American to pay money to a specific industry. They will be forced to pay money to hospitals and doctors to pay for the care of people who do not buy insurance and then need expensive medical care. Even if they are sent to county facilities, it is still the taxpayer picking up the slack. I am more comfortable forcing people to take financial responsibility for their own healthcare, than forcing everyone to take financial responsibility for the people in society who choose not to buy insurance.

We cannot take away the right to sue from anyone. That is not the solution to the malpractice problem. If true malpractice occurs, it does not matter who paid for the care.

I've heard that as well. Cash practices tend to attract a large blue-collar clientele. This is pretty much what I do. I carry a near catastrophic health insurance plan, and I tend to negotiate cash payments for primary care. Interestingly enough, those gold-plated insurance plans only came into existance in retaliation to FDRs price controls during the great depression as a way to entice employees (since it was illegal to just pay more).

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Pretty much and now they are the standard. I would much rather companies pay the money they would of used to buy insurance directly to employees and let them pick an individual plan that suits them best. With some tax break to counteract the higher taxes with this increase in pay.

However thats a drastic step and no doubt politicians would scream that their opponents are trying to take away your health insurance and people would buy it hook line and sinker. Alternatively I think the model Whole Foods is a good starting point. They purchase catastrophic plans for their employees and also deposit 1500 a year into HSA accounts for them.

I don't think we should want our society to determine where patients will be treated based on insurance status rather than proximity and resources of the hospital. Especially in the case of a catastrophic event, time can be one of the most important factors. If a patient has to drive 10 more miles to the county facility, that could be the difference between life and death.

Although EMTALA is a bad law, it was envisioned to prevent just this type of scenario. Hospitals are required to examine and stabilize a patient before transferring to another facility. In emergencies this is a good thing. A private hospital should not be able to refuse someone who could be actively dying due to lack of insurance. The problem is that ER staff is getting bogged down examining UTI's and viruses instead of the urgent situations the law should cover. I think EMTALA could be modified to cover only patients presenting with certain symptoms (chest pain, acute abdomen, trauma, etc.).

If we do not force people to get insurance, we are still forcing every American to pay money to a specific industry. They will be forced to pay money to hospitals and doctors to pay for the care of people who do not buy insurance and then need expensive medical care. Even if they are sent to county facilities, it is still the taxpayer picking up the slack. I am more comfortable forcing people to take financial responsibility for their own healthcare, than forcing everyone to take financial responsibility for the people in society who choose not to buy insurance.

We cannot take away the right to sue from anyone. That is not the solution to the malpractice problem. If true malpractice occurs, it does not matter who paid for the care.

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Well something gotta give. You cant expect to pay less for a privilaged product and get the same service. That's what everyone refuses to acknowledge despite it actually happening now. Your coverage affects your disposition quietly.

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